Critical Review Article

Conservative treatment of mandibular condyle fractures in children: Case series

Abstract

Fractures of the mandibular condyle are infrequent in children, due to morphologic and other factors. Consequences may include ankylosis of the temporomandibular joint, facial asymmetry and functional disturbances. Conservative treatment is widely accepted, being that close long-term follow-up is fundamental. This report includes 11 cases of children with condylar fractures who were treated at the Interceptive Orthodontics Clinic, Universidad Central de Venezuela Dental School, between 2001 and 2014. Evaluated factors include: age, cause and type of the fracture, treatment performed and follow-up period; which were studied using clinical records: panoramic radiographs, tomograms and photographs before and after treatment. Treatment performed included analgesic, anti-inflammatory drugs, intermaxillary fixation, physiotherapy and functional appliances (hybrids, Klammt, Bionator). Prevalence was 1,50% with falls from heights and traffic accidents the most common cause. Most prevalent fractures were 5 cases of unilateral fractures and 6 cases of bilateral fractures. Conservative treatment was successful in the majority of cases. For most cases satisfactory remodeling of the condyle was attained, with some morphologic variations; no ankylosis, facial asymmetry or functional anomalies were observed after treatment.

Case Report

Abstract

Fractures of the mandibular condyle are infrequent in children, due to morphologic and other factors. Consequences may include ankylosis of the temporomandibular joint, facial asymmetry and functional disturbances. Conservative treatment is widely accepted, being that close long-term follow-up is fundamental. This report includes 11 cases of children with condylar fractures who were treated at the Interceptive Orthodontics Clinic, Universidad Central de Venezuela Dental School, between 2001 and 2014. Evaluated factors include: age, cause and type of the fracture, treatment performed and follow-up period; which were studied using clinical records: panoramic radiographs, tomograms and photographs before and after treatment. Treatment performed included analgesic, anti-inflammatory drugs, intermaxillary fixation, physiotherapy and functional appliances (hybrids, Klammt, Bionator). Prevalence was 1,50% with falls from heights and traffic accidents the most common cause. Most prevalent fractures were 5 cases of unilateral fractures and 6 cases of bilateral fractures. Conservative treatment was successful in the majority of cases. For most cases satisfactory remodeling of the condyle was attained, with some morphologic variations; no ankylosis, facial asymmetry or functional anomalies were observed after treatment.

Introduction

Mandibular condyle fractures are traumatic injuries that may produce discontinuity of neighboring structures, accompanied with alterations in normal mandibular excursions.1

Facial and oral traumas occur frequently throughout infancy, with prevalence range from 28% to 60%. Mandibular fractures are the most common facial fractures in children. Condylar fractures constitute 50% of all mandibular fractures in children. The condyle is the most fragile and vulnerable structure in the mandible.2-5

Although the mandibular condyle is well protected from direct trauma, it may suffer fractures from indirect trauma, secondary to trauma to the chin.6

Causes for condylar fractures vary between locations and societies. Amaratunga7 states that most common causes for children in Sri Lanka differ from eastern countries and include falls from heights and traffic accidents. In the U.S.A, U.K. and Eastern Europe the most common causes are traffic accidents. In the Nederland, where bicycles are used for transportation, cycling accidents are the main cause of condylar fractures. Dimitroulis8 suggests that etiology is age related and linked with most common activities performed by the patients.

Consequences of condylar fractures on craniofacial growth and development are particularly important. They may include TML ankylosis, facial asymmetry and functional disturbances. Prevention of these possible sequels may be attained by appropriate treatment, considering fracture type.14

Authors such as Dimitroulis,8 Defabians,9 Peterson,10 Medina,14 Lobo,16 Noleto, 17 Choi,18 Girthofer19 vouch for conservative treatment and suggest that it results in proper mandibular function and mouth opening with reduction of facial asymmetry and mandibular deviation, condylar remodeling with few sequel.

Physiotherapy seeks to modify or reduce improper habits or function with negative impact on craniofacial growth and development. It aims to correct occlusal relation by performing open-close and lateral movements, and increase mouth opening by using bite blocks.20

Early functional appliance treatment for pediatric patients with condylar fractures stimulates proper growth of the soft tissues and condyles. This is an important aspect in the treatment of condylar fractures because early mobilization of the articulation and surrounding structures reduces mechanical restrictions caused by scar tissue formation and lack of movement, and improve bone remodeling.9

The aim of this research is to evaluate a case series of pediatric patients treated at the Interceptive Orthodontics Clinic, Pediatric Dentistry Postgraduate Program, who presented with condylar fractures. Studied variables include demographic characteristics, condylar fracture classification, treatment performed, radiographic changes in condylar anatomy before and after treatment, and facial asymmetry before and after treatment.

Materials and Methods

This is a retrospective, longitudinal, documentary and comparative study, that analyzes previously recorded diagnostic records, clinical charts, photographs and radiographs from a series of cases.

Population was composed of all patients who attended the Interceptive Orthodontics Clinic of the Pediatric Dentistry Postgraduate Program from 2001 to 2014. Tha sample was selected including all patients with condylar fractures.

Inclusion criteria were: children with condylar fracture who were otherwise apparently healthy and has good quality radiographs in wich both condyles could be clearly observed. These radiographs were previously taken for diagnostic purposes and no radiographs were performed for this research.

Exclusion criteria: Children over 14 years of age, syndromes or systemic disease, incomplete diagnostic records, surgical treatment or growth pathologies.

Variables assessed included: condylar fracture (level: Condylar head or intracapsular; high, medium or low condylar neck, Subcondylar; Number of fractures: simple, multiple or comminute; Condylar head position in relation with the glenoid fossa: green stem, displaced, dislocated; and Special situations: open or closed), facial symmetry, opening deviation.

Treatment outcome was considered satisfactory if the patient and proper mandibular function, without ankylosis, appropriate mandibular excursions although some anatomical alteration could be observed. Not satisfactory outcome was considered if patient presented ankylosis, TMJ disorders or referred pain.

The observers were previously trained for image observation and fracture diagnosis.

Demographic data was retrieved from the clinical charts. Each radiograph was observed using a netagoscope for fracture identification and classification, registering type of fracture and anatomical characteristics. Data registered included treatment performed, short and log term outcomes. Photographs were observed to determine facial symmetry.

This project did not receive funding and received Ethics Committee approval No 0450-2012. Authors declare no conflict of interest. Treatment performed for each patient was determined by individual needs, standard international guidelines, and known scientific evidence and not manipulated in any way for research purposes.

Results

The sample was selected by convenience following the established inclusion criteria. Total population was 867 cases treated at the Interceptive Orthodontics Clinic of the Pediatric Dentistry Postgraduate Program from 2001 to 2014. The sample was composed by 11 patients, 5 boys and 6 girls, for a prevalence of 1,50%. Average age for trauma occurrence was 6.85 years, with patients aged 1 to 14 year of age.

In compliance with exclusion criteria, 3 cases were excluded due to uncertain initial diagnosis. 3 patients reported previous condylar fractures at a very early age, but lacked initial radiographs to confirm diagnosis. Of these patients2 presented with TMJ ankylosis, 1 with severe facial asymmetry and has received initial surgical treatment.

Most common causes of condylar fractures were falls from hights (7 cases), traffic accidents (3 cases), fall from own feet (1 case).

Out of 11 patients, 6 had bicondylar fracture and 5 had unilateral fractures for a total of 17 fractured condyles.

Fracture characteristics evaluated included fracture level, number of fractures, condylar head position and special situations. 100% of cases were closed fractures. (Fig. 1)

Type of condylar fracture according to the relation of the condylar head position with the glenoid fossa were: 8 dislocated fractures, 4 displaced fractures, 3 non displaced fractures, 2 cases with incomplete records.

Deviation in mouth opening was analyzed as present or absent. For initial evaluation 2 cases had deviation, 4 had no deviation, 5 had incomplete data. At the latest evaluation, 5 cases had no deviation in mouth opening and 6 cases has incomplete data.

Average age for starting treatment was 7 years of age. Type of therapy varied fron physiotherapy, antibiotic therapy, analgesics, conservative therapy including bite blocks, functional orthopedics, and closed intermaxillary fixation.

Most cases used combination of therapies. Treatment time varied from 6 months to 2, 6 and 7 years follow-up in some cases. (Fig. 4)

Discussion

The mandibular condyle is the most fragile stricture of the facial skeleton and most frequently suffers consequences when there is trauma to the facial region producing condylar fractures.2-5 From all fractures of the facial structures that occur in children, the mandibular condyle is most affected due to the skeletal configuration of the face and that it is a less compact bone with high proportion of medullar bone surrounded by a thin cortical layer.16,22

In this case series study prevalence was 1.50%. This is a rather low prevalence and may be due to the nature of the Interceptive Orthodontics Clinic. It is a referral clinic and not set in an hospital facility or emergency service.

References state that causes of condylar fractures in children depend on age, most frequent activities engaged, socioeconomic status, demographic conditions, and cultural and environmental factors. Main causes are falls, bicycle and traffic accidents.6-8,12,14,16

Child abuse must also be considered as a possible cause when diagnosing condylar fractures.23

For this case series, the most common cause was fall from heights (64%) for children under the age of 12, in accordance with previous studies. Most patients fell from unprotected heights in their homes, where no security railing is installed in stairways or flights and safety conditions are deplorable.

Literature reports that prevalence for condylar fractures is higher in males and increases with age.6-9,12,15,20 In this case series prevalence was higher for females.

Pediatric dentists, as part of the multidisciplinary team, relay on a series of clinical and radiographic records that allow proper diagnosis for condylar fractures. One of the most common clinical signs is laceration or bruising of the chin.8,10,32

Regarding fracture classification, many systems have been proposed involving condylar anatomy, localization of the fracture, relation to teeth and exposure.10,28,30

Several studies sustain that most condylar fractures in young patients are intracapsular and high condylar head, and least common fractures are subcondylar or low condylar head. Unilateral fractures are three times more common than bilateral fractures.3,7,10,15,28,32

In this case series, 6 children had bilateral fractures, differing from literature reports, and most common localization was high condylar head (76%), similar to previous studies.

Dislocation from the glenoid fossa occurs in 39% of all condylar fractures in children, requiring extensive bone remodeling to achieve normal anatomic relation.6 Overall, these types of fractures usually present incomplete remodeling, abnormal neck and articular morphology. Mandibular asymmetry and log term squeals are frequent consequences of these types of fractures.6

In this case series, displaced fractures were observed for 50% of the fractures. Despite the fact that initial condylar anatomy was severely altered or presented with loss of normal anatomy these patients did not present with facial asymmetry, contrary to cases reported by Thorén.6

Conservative treatment is mostly recommended for condylar fractures in children. Clinical experience has demonstrated good results in most cases. Treatment course includes: physiotherapy (mouth opening-close movements), bite blocks or piled wooden tounge depressors to increase mouth opening and functional appliances to maintain the mandible in proper position, stimulating proper function and guiding growth. Treatment may depend on patients age, damage to the condyle and time elapsed since the fracture and treatment commencement. (Table 1) 6-7,9,11,14-19,22,38-44

Table 1. Literature review summary

Intermaxillary fixation (IMF) is the normal restoration of the occlusion by means of immobilizing the mandible with intemaxillary elastics or wire ligatures. If necessary, it may be followed with physiotherapy or the use of functional appliances. 11,18,21,30 In tis case series, only 1 patient was treated with IMF, followed by physiotherapy and functional appliances with good outcome. 7 cases used bite blocks made out of piled wooden tongue depressors, with good results in accordance with other studies.6,8-10,36

The choice of which functional appliance to use depends mainly on fracture type and severity, patients dental and cephalometric diagnosis.14 This case series is in accordance with other reports in which children were treated with this type of appliances with favorable outcome. Patients did not present with facial asymmetry, ankylosis, deviation in mouth opening, TMJ problems; although some anatomical variations were observed. 3,6-10,14,16,17,19,40-42

In children under the age of 12, conservative treatment is feasible due to the condyles high morphological and functional regenerative capacity in growing patients.6-8

Despite the literature reports stating that in children over 12-14 years of age treatment must be surgical as in adults (on behalf of expected poor condylar remodeling), in this case report one 12 year old boy with displaced and dislocated condylar fracture was successfully treated using physiotherapy and functional appliances, obtaining good condylar remodeling.

2 patients with high condylar neck fractures, aged 1 to 3 years, with facial asymmetry, were treated with functional appliances (Quirós-Crespo y Klammt). Treatment started 2 to 8 months after sustaining the fracture. In both cases outcome was good for a 7 year follow-up.

Diagnosis of condylar fractures is most commonly performed using panoramic radiographs. Peterson 10 y Dimitroulis 8 state that these radiographs are easily accessible to dentists. Ellis (2000) sustains that this technique gives information regarding localization and existence or not of condylar displacement, but does not have proper resolution. This is why it has been almost completely replaces by computed tomography (CAT scan).45

In the cases here reported diagnosis was performed with panoramic radiographs. Only one case had computed tomography performed at the initial diagnosis. In some developing countries, public hospitals do not perform routine CAT scans and dentists do not prescribe them due to high costs. Nevertheless, it should be the routine diagnostic tool for condylar fractures.

TMJ ankylosis is a frequent complication of bilateral condylar fractures. Spontaneous consolidation of a condylar fracture may produce functional ankylosis, resulting in mandibular and related structure deformity. It is possible for ankylosis to affect normal growth. The mandible may be able to achieve some restricted movements, but the condylar head has limited displacement from the glenoid fossa.15,17

In this study, none of the cases reported presented ankylosis disregarding patients age, type of fracture or treatment received. This is of great importance because ankylosis is the most severe possible complication of condylar fractures.

Patient follow-up is of upmost importance. Periodical clinical and radiographic examination must be performed throughout growth until permanent occlusion is stable, so any complication may be promptly diagnosed and treated.

A limitation of this study is that several cases here reported had missing or incomplete initial and final records, thus making it impossible to campare outcomes. (Table 2) Standardization of data registry and follow-up is advised for future studies.

Table 2. Diagnosis, treatment, follow-up of studied cases.

Interdisciplinary management for patients with condylar fractures is key for proper outcome. Oral and maxillofacial surgeons, pediatric dentists and orthodontists must be evolved to ensure best and most efficient treatment plan throughout growth and development of the facial skeleton.

Conclusions

Fractures of the mandibular condyle are infrequent in the studied population, representing 1.50% of cases. Average age for accordance of the fracture was 6 years old. Girls were most frequently affected.

Most frequent causes for condylar fracture in this sample wer fall from heights (64%) and traffic accidents (27%).

The most frequent type of fracture was unilateral, simple, and dislocated.

Conservative treatment, including physiotherapy and functional appliances, was successful for most cases. As a result, proper condylar remodeling, with occasional anatomic variants, appropriate facial symmetry and mandibular excursions. No case presented TMJ ankylosis.

Critical Review Article

Abstract

Fractures of the mandibular condyle are infrequent in children, due to morphologic and other factors. Consequences may include ankylosis of the temporomandibular joint, facial asymmetry and functional disturbances. Conservative treatment is widely accepted, being that close long-term follow-up is fundamental. This report includes 11 cases of children with condylar fractures who were treated at the Interceptive Orthodontics Clinic, Universidad Central de Venezuela Dental School, between 2001 and 2014. Evaluated factors include: age, cause and type of the fracture, treatment performed and follow-up period; which were studied using clinical records: panoramic radiographs, tomograms and photographs before and after treatment. Treatment performed included analgesic, anti-inflammatory drugs, intermaxillary fixation, physiotherapy and functional appliances (hybrids, Klammt, Bionator). Prevalence was 1,50% with falls from heights and traffic accidents the most common cause. Most prevalent fractures were 5 cases of unilateral fractures and 6 cases of bilateral fractures. Conservative treatment was successful in the majority of cases. For most cases satisfactory remodeling of the condyle was attained, with some morphologic variations; no ankylosis, facial asymmetry or functional anomalies were observed after treatment.